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Breast Imaging Patient History / Pase Pasyan ak Imajri Pou Tete Patient Name/ Non Pasyan: ______________________________________Today’s Date/ Jodiya: ______________ Date of Birth/ Dat Nesans: _______________ Phone# / Telefòn: ____________________________ Ordering Physician/ Doktè Ki Kòmande l la: ________________________________ No/Non Yes/Wi 1. Have you had a previous mammogram? Èske ou janm fè yon mamogram deja? If Yes/ Wi: When/Ki lè? _______________ Where/Ki Kote?_____________________ 2. Have you had a previous Breast MRI or Breast Ultrasound? Èske ou janm fè yon IRM pou Tete oubyen Ekografi pou Tete deja? If Yes/ Wi: When/Ki lè? ___________________ Where/Ki Kote?_____________________ 3. Are you having any NEW areas of pain in your breast(s)? Èske ou gen okenn NOUVO kote nan tete ou(yo) kap fè ou mal? 4. Have you or your doctor recently found a NEW lump or mass in your breast(s)? Èske ou menm oswa doktè ou te fenk jwenn yon NOUVO boul ou mas nan tete ou (yo)? 5. Are you having any NEW nipple discharge or NEW puckering of the skin or nipple? Èske ou gen okenn NOUVO dlo kap soti nan pwent tete ou oubyen èske po a oubyen pwent tete a fenk KÒMANSE ap plise? 6. Have you had any prior breast surgery? Èske ou te fè okenn operasyon nan tete deja? If Yes/ Wi: When/Ki lè? _________ Aspiration/Aspirasyon:Right/Dwat Left/Goch Reduction/Rediksyon ___Implants /Enplant Other/Lòt _______________________________ 7. Do you have a history of breast cancer? Èske ou gen konn gen kansè nan tete? If Yes/ Wi: When/Ki lè? __________ Location/Ki Kote (please circle)/(Tanpri Antoure): Right/Dwat Left/Goch Both/Tout De Mastectomy/Retire Tete Lumpectomy/Retire Boul Chemotherapy/Chimyoterapi # of Treatments/Tretman _____ Radiation/Radyoterapi # of Treatments/Tretman:_____ 8. Do you have a family history of breast cancer? Èske gen moun nan fanmi ou ki gen kansè nan tete? If Yes/ Wi: Age/Laj _______ Mother/Manman Sister/Sè Daughter/Pitit Fi Other/Lòt_______________________________ 9. Are you taking any hormone replacements? Èske w ap ran okenn tretman pou ranplase òmòn? 10. Is there any possibility you may be pregnant? Èske gen okenn posiblite ou ka ansent? 11. What is the date of your last menstrual period? Ki dat dènye jou ou te gen règ ou? Date/Dat: _______________ ALL MAMMOGRAPHY PATIENTS: Please read and initial/TOUT MAMOGRAM: li sa ki pi ba Lea a epiy mete inisyal initial PARA PASYAN TODAS LAS PACIENTESTanpri DE MAMOGRAFÍA: coloque sus ou iniciales (premye lèt chakthat nonmammograms w) a. I understand do not detect all breast cancers and that they must be combined with periodic physical a.exam, ______Initials I understand thatand mammograms do notanydetect breast cancers and that they must be combined with monthly breast self-exam, comparison with priorall mammograms. periodic physicalEntiendo exam, monthly self-exam, and comparison anydeprior mammograms. ______Iniciales que lasbreast mamografías no detectan todos loswith tipos cáncer de seno y que se deben combinar con ______Inisyal Mwen konprann mamogram yo pa detekte tout kansè ki nan tete epi yap oblije melanje ak egzamen fizik examines físicos periódicos, autoexámenes de seno mensuales y comparaciones con mamografías anteriores. regilye, egzamenthat teteany mwen mwen menm mwa, ak konparezon nenpòt te fènow, avan.it is my b. I understand timefèI develop a newchak breast problem OR if I amavèk having any mamogram new breast mwen problems b. ______Initials I understand any time I and develop problem OR iftime I amofhaving any new breast problems now, it responsibility to report this tothat my physician, also atonew the breast technologist at the my mammogram. is______Iniciales my responsibility to report myque physician, alsoproblema to the technologist timeteniendo of my mammogram. Entiendo que this cadatovez tenga unand nuevo de senos Oatsithe estoy nuevos problemas de senos _____Inisyal Mwen konprann nenpòt lè mwen devlope yon nouvo pwoblèm nan tete OU si mwen gen nenpòt nouvo pwoblèm ahora, es mi responsabilidad informar a mi médico así como a la tecnóloga en el momento de la mamografía. nan tete mwen kounye a, se responsabilite mwen pouforrapòte sa bay mammogram doktè mwen, ansanm lè m ap fèI may mamogram c. I understand that anytime I have been scheduled a screening but haveaka teknolojis new breastla problem, need to nan. have a diagnostic mammogram and/or breast ultrasound, which my physician will need to order. c.______Iniciales ______InitialsEntiendo I understand that anytime I have una beenmamografía scheduled for a screening mammogram haveuna new que cada vez que tenga de detección programada perobuttenga nuevobreast problema de problem, may need have que a diagnostic and/or breast ultrasound, which mydephysician willmineed to order. senos, esI posible quetotenga hacermemammogram una mamografía de diagnóstico o un ultrasonido senos, que médico tendrá que_____Inisyal solicitar. Mwen konprann nenpòt lè mwen gen randevou pou yon egzamen mamogram men mwen gen yon nouvo pwoblèm nan tete, kapab bezwen fè yon mamogram poumammogram detekte kansèresults. ak/ou yon ekografi tete doktè mwen pral bezwen d. I understand thatmwen I must contact my physician for my final kòmande. ______Iniciales Entiendo que debo comunicarme con mi médico para obtener los resultados finales de mi mamografía. d. ______Initials I understand that I must contact my physician for my final mammogram results. Patient Signature/ ______Inisyal mwen konprann mwen oblije kontakte doktè mwen pou konnen rezilta final mamogram mwen an. Patient Signature/Siyati Pasyan: _____________________________________ Date/Dat: ___________________ FOR TECHNOLOGIST USE ONLY: MRN# ______________ Technologist Comments: _____________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Revised 7-2012 ________
